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We understand the nuances of documentation, and will personally train your therapists on how to maximize profits.

Why People Trust Us

We are not an algorithm.  We are real, highly skilled therapists behind every audit.  We understand the nuances of documentation and how to address them in human language.

High ROI

We consistently deliver value by increasing your bottom line.

Unmatched Expertise

The human touch is a game changer in reducing unnecessary denials.

Qualified Staff

All of our staff are experienced, licensed therapists.

Responsibilities of the Documentation Specialist include:

Conducting patient clinical and billing chart reviews (Typically 2-3 patients of various treatments – i.e. Evaluations, Daily notes, Re-evaluations, etc.)

Providing a written recommendation report to the therapy provider

Providing a corrective action plan to the therapy provider using the Documentation Specialist’s audit template

Providing resources and references to the therapy providers to help improve their documentation

Providing phone support to therapy providers and/or administration regarding audit specific findings

Providing EMR phone or video training to individuals or groups as needed

Attend company meetings as needed via video conferencing

Our Documentation Specialists review every chart and offer recommendations to the therapy providers for continuous improvement.


Upon completion of the audit, a report is generated for the therapy provider to highlight the strengths and weaknesses of their documentation. In addition, a tailored recommended action plan is generated to help them improve. Each audit performed by the Documentation Specialist will include expert feedback to the therapy provider by using our comprehensive audit template. At the end of the audit a letter grade will be provided to the therapy provider to reflect their overall documentation skill level.

What We Do

Ensure That:
- Skilled need is justified in the therapist’s documentation
- Documentation supports medical necessity
- The therapist’s daily notes are distinctive and ethical
- Appropriate billing compliance (CPT code and modifier selection, proper units, etc.)
- Therapy providers are following National Correct Coding Initiatives (NCCI)
- Documentation is not missing frequency and duration of exercise prescription, physician and therapist’s signatures, dates, and total treatment time
- Therapy treatments and documentation support the CPT billing codes
- Abbreviations are not overused

We ensure that your documentation is compliant with Medicare/Medicaid state and federal guidelines, as well as all private insurance companies increasing your cash flow by reducing denial rates. Our services are unique because every audit is performed by highly knowledgeable and experienced licensed therapists, specializing in our proprietary audit methodology.

Who We Serve

No matter where you are in your documentation processes, we’re here to help!